Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

PURPOSE: We sought to investigate the prevalence and variables associated with early oncologic failure. MATERIALS AND METHODS: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival. RESULTS: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38–5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00–6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21–3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001). CONCLUSIONS: The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy

Development of a patient and institutional-based model for estimation of operative times for robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium

OBJECTIVES: To design a methodology to predict operative times for robot-assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control. PATIENTS AND METHODS: The model included preoperative variables and therefore can be used for prediction of surgical times: institutional volume, age, gender, body mass index, American Society of Anesthesiologists score, history of prior surgery and radiation, clinical stage, neoadjuvant chemotherapy, type, technique of diversion, and the extent of lymph node dissection. A conditional inference tree method was used to fit a binary decision tree predicting operative time. Permutation tests were performed to determine the variables having the strongest association with surgical time. The data were split at the value of this variable resulting in the largest difference in means for the surgical time across the split. This process was repeated recursively on the resultant data sets until the permutation tests showed no significant association with operative time. RESULTS: In all, 2 134 procedures were included. The variable most strongly associated with surgical time was type of diversion, with ileal conduits being 70 min shorter (P 66 RARCs) was important, with those with a higher volume being 55 min shorter (P < 0.001). The regression tree output was in the form of box plots that show the median and ranges of surgical times according to the patient, disease, and institutional characteristics. CONCLUSION: We developed a method to estimate operative times for RARC based on patient, disease, and institutional metrics that can help operating room scheduling for RARC

Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

INTRODUCTION AND OBJECTIVE: This study aims to provide an update and compare perioperative outcomes and complications of Intracorporeal urinary diversion (ICUD) and extracorporeal urinary diversion (ECUD) following RARC from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC). METHODS: A retrospective review of 2125 patients from 26 institutions was performed. ICUD was compared with ECUD Multivariate (stepwise variable selection) logistic regression models were fit to evaluate preoperative, operative, and postoperative predictors of receiving ICUD, operative time, high grade complications and 90-days readmissions after RARC. RESULTS: 51% (n=1094) patients underwent ICUD in our cohort. ICUD patients demonstrated shorter operative times (357 vs 400 minutes, p<0.001), less blood loss (300 vs 350 ml, p<0.001), and fewer blood transfusions (4% vs 19%, p<0.001). ICUD patients experienced more high grade complications (13 vs 10%, p=0.02). Utilization of ICUD increased from 9% of all urinary diversions in 2005 to 97% in 2015. Complications after ICUD decreased significantly over time (p<0.001). On multivariable analysis, higher annual cystectomy volume (OR 1.02, 95% CI (1.01-1.03), p<0.002) and year of RARC 2013-2016 (OR 68, 95% CI 44-105, p<0.001) and ASA score <3 (OR 1.75, 95% CI 1.38-2.22, p<0.001) were associated with receiving ICUD. ICUD was associated with shorter operative time (27 minutes, p=0.001). CONCLUSION: Utilization of ICUD has increased over the past decade. Higher annual institutional volume of RARCs was associated with performing ICUD. ICUD was associated with shorter operative times. Although ICUD was associated with higher grade complications compared to ECUD, they decreased over time

LHRH agonists in prostate cancer:frequency of treatment, serum testosterone measurement and castrate level: consensus opinion from a roundtable discussion

Background: Options for lowering testosterone in patients with prostate cancer include bilateral orchiectomy, oestrogens and luteinising hormone-releasing hormone (LHRH) agonists. LHRH agonists have become widely used in the treatment of prostate cancer. Roundtable assembly: In May 2006, a team of experts convened a roundtable assembly to discuss key issues associated with the use of LHRH agonists in the treatment of prostate cancer. Roundtable discussion: The discussion centred on the frequency of treatment with LHRH agonists, the role of serum testosterone (ST) measurement as part of routine follow-up, and the recommended castrate level of ST. Several formulations of LHRH agonists are available, including 3-month depots that coincide with visit frequency for prostate-specific antigen (PSA) testing. Appropriate monitoring of patients receiving LHRH agonists continues to be based on PSA levels. ST determination is not recommended as part of routine follow-up, and does not provide additional prognostic benefit or improved overall management for the majority of patients. However, determination of ST may be useful in selected patients, such as those with rising PSA levels or in cases where there is doubt over LHRH agonist administration or absorption. Achieving levels of ST similar to those obtained after orchiectomy is important for patient outcomes, although there is no evidence that a lower ST level (<50 ng/dl) results in additional clinical benefits. Conclusions: LHRH agonists should be considered first-choice testosterone-lowering therapy for the treatment of prostate cancer, with the 3-month depot formulation providing optimal convenience and flexibility. Assessment of patients receiving LHRH agonists should be based on PSA levels rather than ST levels, although levels of ST similar to those obtained after orchiectomy still need to be achieved. Further studies are warranted before the potential therapeutic benefit of considerably lowered ST levels can be fully assessed